not just in the books

I had a very puzzling experience last night. The arrest pager went off, and I happened to be just one floor above, so I got there a good deal faster than most of the rest of the response team, several floors below. So when I arrived, it was just a few of the floor nurses and an aide. One was making a respectable (although to my mind not very successful) attempt at bagging. Another was doing compressions, and stopping every few seconds to look at the monitor. To me, the monitor looked like torsades immediately, the only time I’ve ever seen that rhythm in real life.

Finding myself the only doctor on the scene willing to talk (the interns had a deer-in-the-headlights look), I announced, “That looks like torsades. It’s a shockable rhythm. Where’s the defibrillator?” One nurse pointed out that she was attaching the pads to the machine, while the other two immediately contradicted me, saying that the rhythm was not torsades, or that it was not shockable. They kept doing compressions.

Clearly I need to learn how to talk louder in emergencies – that particular crowd-control voice which rides right over all the other noise, without being quite as energetic as shouting. (The first time I was alone in the ER with a bad trauma, I found myself squeaking quite shockingly. At least now I lower my voice, instead of raising it, to get control.) It took a little bit of effort to get them to stop compressions long enough to get a real read on the monitor, and strangely enough it was torsades (torsades de pointes, a particular type of ventricular fibrillation, where the waves alternate in height); in this case, it was a beautiful spindly pattern, completely classic (says me, the first time I’ve seen it). Then of course there was the matter of figuring out how the defibrillator worked (an area where I will freely admit that once I got them to go along with me, the nurses were better at the mechanics than I was). We shocked him once, and it worked almost immediately.

The entire event felt surreal. For one thing, torsades. I was starting to think they were purely a textbook phenomenon, like Janeway lesions and Osler’s nodes, antique entities that no longer visit us in real life. Then, the nurses. They were specialty cardiac nurses, twice my age, but seriously? They’ve worked with me off and on for two years. Why didn’t they recognize that it was at least some variety of vfib, and why were they arguing with me? And lastly, the defibrillator worked immediately. That made the whole thing feel like a badly scripted episode from ER: conflict between resident and nurses, and then the defibrillator working like magic. I was so surprised by that, it took me a second to think of what we ought to do next (intubate the poor fellow, who was still blue, despite a strong pressure). (And for icing, the interns standing by gaping at me and the nurses. Yes, it’s June. Yes, these were the old interns. Don’t ask any more questions.)

In any case, for all the chaos, it was the most perfect code I’ve ever been to, and the most perfect code I’ve ever run. So much nicer than the usual asystole arrests, where you can’t shock, just do compressions and push drugs and it never really works that well. Next time I’m going to see if I can not blank out when looking at the defibrillator.

(And yes, as various people pointed out to me later, the textbooks also say that magnesium is the appropriate treatment for torsades. To which I say, 1, I’m not going to discuss whether I remembered that detail or not; 2, in any case, in a code on a regular nursing floor, one has a much better chance of getting the defibrillator to work than of finding magnesium and pushing it fast enough to make a difference. Next time, we’ll schedule the torsades, and arrive with magnesium in hand. The discussion with the nurses was about the diagnosis, not the treatment.)

Those people who point out that MgSO4 is appropriate for torsades also forget that the treatment for pulseless VT (which this was, if they were doing compressions) is amps first and foremost. (Not too many amps, a small fraction in fact, but still amps.)

Every time I read something about someone in a position of authority not being listened to, I have to remind myself that not everyone has had military leadership training. Learning the “command voice” (a combination of pitch and modulation that seems to be able to cut through nearly any other noise and mental blockage) is a vital skill, but one that really can only be learned by example. See if you can’t find yourself some old drill sergeants to hang out with for a while, it’s an amazing tool…